Nokea
The nurse is aware that a 65-year-old widower whose only son is 500 miles away is at higher risk for psychosocial distress because the client:
- A. Has been successful in dealing with stress all his life.
- B. Does not have to deal with other stressors right now.
- C. Is able to use denial as a coping mechanism.
- D. Perceives he has minimal social support.
Correct Answer: D
Rationale: Minimal social support, due to being widowed and geographically isolated from his son, increases the risk of psychosocial distress in this cancer client.
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The nurse teaches the client with chronic cancer pain about optimal pain control. Which of the following recommendations is most effective for pain control?
- A. Get used to some pain and use a little less medication than needed to keep from being addicted.
- B. Take prescribed analgesics on an around-the-clock schedule to prevent recurrent pain.
- C. Take analgesics only when pain returns.
- D. Take enough analgesics around the clock so that you can sleep 12 to 16 hours a day to block the pain.
Correct Answer: B
Rationale: Taking analgesics around-the-clock prevents recurrent pain by maintaining steady drug levels, which is the most effective strategy for chronic cancer pain.
Prior to surgery, the nurse is instructing a client who will have a total hip replacement tomorrow. Which of the following information is most important to include in the teaching plan at this time?
- A. Teaching how to prevent hip flexion.
- B. Demonstrating coughing and deep-breathing techniques.
- C. Showing the client what an actual hip prosthesis looks like.
- D. Assessing the client's fears about the procedure.
Correct Answer: A
Rationale: Preventing hip flexion is critical to avoid dislocation post-surgery.
Palpation of the skin provides the nurse useful information regarding:
- A. Bruising of the skin.
- B. Color of the skin.
- C. Hair distribution.
- D. Turgor of the skin.
Correct Answer: D
Rationale: Palpation assesses skin turgor, indicating hydration status. Bruising and color are visually assessed, and hair distribution is observed, not palpated.
The nurse is teaching a client with osteoarthritis about assistive devices. Which device is most appropriate for ambulation?
- A. Standard cane.
- B. Wheelchair.
- C. Four-wheeled walker.
- D. Crutches.
Correct Answer: A
Rationale: A standard cane provides support and stability for clients with osteoarthritis during ambulation.
When teaching the client to care for an ileal conduit, the nurse instructs the client to empty the appliance frequently. Which of the following indicate that the client is following instructions?
- A. The skin around the stoma is red.
- B. The urine is a deep yellow.
- C. There is no odor present.
- D. The seal around the stoma is intact.
Correct Answer: C,D
Rationale: No odor and an intact seal indicate frequent emptying, preventing urine leakage and skin irritation. Red skin or deep yellow urine suggest inadequate care or dehydration.